Organ transplant sole ch11

General symptoms - pain to specific organ, maybe fever, dysfunction of specific organ, fatigue, maybe n/v

do a biopsy, increase immunosuppression therapy (IV)

s/s of kidney OTx rejection

S/S
  * Fever
  * Edema
  * Gross hematuria
  * Pain
  * Increased BUN and creatinine
  * Weight gain
  * Elevated blood pressure
  * Decreased urine output
  * Bruit over artery anastomosis site
  * Hyperacute: increased temp, increased BP, pain at Tx site.
  * Acute: oliguria or anuria, temp 100+, increased BP, enlarged tender kidney, lethargy, elevated creatinine, BUN, K+, fluid retention.
  * Chronic: gradual increase in BUN and creatinine, fluid retention and electrolyte imbalance, fatigue.

monitoring the patient post kidney OTx

carefully monitor fluid and electrolyte imbalances Q4-6 hrs
* Excessive diuresis common with live donor donation - monitor hypotension, K+ and Na+
weigh daily
BP q2-4 hr
urine output hourly for the first 48 hours.
* typically pink and bloody post surgery, lasts days to weeks.
Daily UA, glucose measurement, acetone level, spec. grav.
continuous bladder irrigation may be indicated to reduce clotting in the bladder.
CAUTI precautious, remove catheter ASAP, typically 3-5 days.
hemodialysis may be needed with transplant from a cadaver (live donor kidneys start working right away)
hemoglobin and hematocrit are monitored closely as chronic anemia is common with ESRD
monitor for these disease processes as the patient will be on immunosuppressants
  * nephrotoxicity
  * HTN
  * Hyperlipidemia
  * Bone loss
  * New onset DM
  * Infection
teach to avoid large crowds or anyone who has recently gotten a live vaccine

Care for a Client Undergoing Stem Cell Transplant

The period after transplantation is very difficult and risky
Infection and poor clotting with bleeding are severe problems because the patient remains without any immunity until the transfused cells grow and engraft
Helping the patient maintain hope through this long recovery period is challenging
Encourage the patient to express his or her feelings and concerns while maintaining a supportive presence and trusting nurse-patient relationship
Other complications of hematopoietic stem cell transplant (HSCT) include failure to engraft, development of graft-versus-host disease (GVHD), and sinusoidal obstructive syndrome (SOS)
  * Failure to graft: occurs when the donated stem cells fail to grow and fail to function in the bone marrow (less common with autologous donations)
  * The causes include too few cells transplanted, attack or rejection of donor cells by the recipient’s remaining immune system cells, infection of transplanted cells, and unknown biologic factors
    * If the transplanted cells fail to engraft, the patient will die unless another HSCT procedure is successful
  * Sinusoidal obstructive syndrome (SOS): the blockage of liver blood vessels by clotting and inflammation (phlebitis) and occurs in about one-fifth of patients with HSCT
  * Problems usually begin within the first 30 days after transplantation
  * Symptoms include jaundice, pain in the right upper quadrant, ascites, weight gain, and liver enlargement
  * Because there is no way of opening the liver vessels, treatment is supportive
  * Fluid management is also crucial. Assess the patient daily for weight gain, fluid retention, ascites, and hepatomegaly
During the period of greatest bone marrow suppression (the nadir), the patient is an extreme risk for bleeding
  * Assess at least every 4 hours for evidence of bleeding: oozing, enlarging bruises, petechiae, or purpura.
  * Inspect all stools, urine, drainage, and vomit for obvious blood and test for occult blood.
  * Measure any blood loss as accurately as possible and measure the abdominal girth daily.
  * Increases in abdominal girth can indicate internal hemorrhage
  * Monitor laboratory values daily, especially CBC results, to assess bleeding risk and actual blood loss.
  * The patient with a platelet count below 10,000/mm3 (10 × 109/L) may need a platelet transfusion.
  * For the patient with severe blood loss, packed RBCs may be prescribed
  * Treat pain with NON-aspirin or NSAID containing analgesics, or opioids.
  * Treat fever with APAP.

Contraindications for OTx

malignancy within the past two years, HIV or cancer
lack of adequate social support
significant non-compliance with medication regimen
significant coronary artery disease

Types of rejection after OTx

Types of rejection: (determined by time of occurrence)
  * Hyperacute rejection: minutes-hours post transplantation.
    * due to antibody mediated rejection
  * Accelerated rejection: 24hrs-5 days d/t prior exposure to one of donors antigens.
    * due to antibody mediated rejection
  * Acute rejection: days-3 months. 90% of rejection episodes
    * due to a cell-mediated inflammation/rejection
  * Chronic rejection: months to years after
    * ex: graft dysfunction, arteriosclerosis etc.
To reduce the risk of rejection, human leukocyte antigen (HLA) testing and blood group/type tests are performed

Medication teaching for the patient after OTx

Immunosuppressive med side effects:
  * Anemia
  * Hyperlipidemia
  * Hypertension
  * Bone disease
  * Nephrotoxicity
  * Neurotoxicity
  * New onset DM
  * Nausea
  * Impaired wound healing
  * Hyperuricemia
  * Hyperkalemia
  * Hypomagnesemia
  * Malignancy
  * INFECTION
These meds are FOR LIFE
  * Cyclosporine
  * Mofetil
  * Prednisone

Role of the nurse (Sole)

Critical care nurses work collaboratively with procurement agencies and transplant teams throughout the continuum of care from:
  * identification of a potential donor
  * providing emotional support for the donor families
  * brain death testing
  * donor management
  * organ procurement process
  * emotional support for multiprofessional team members

Lab tests to screen for a match

HLA
blood type testing → ABO blood typing (Rh factor does not matter)
crossmatch test → involves mixing your blood with cells from the donor
* if the crossmatch is positive, it means that you have antibodies against the donor & you should NOT receive this particular organ because your body will destroy it
* if the cross match is negative, it means you do not have antibodies to the organ and you are eligible to receive it
serology → blood testing is conducted for potentially transmissible diseases, such as HIV, hepatitis, & cytomegalovirus (CMV)

Post-op care for lung OTx

first few months after lung transplant surgery are when the pt is at the highest risk for infection or rejection, teach pt about stay away from large crowds
care for the incision site to prevent infection
Exercise regularly
avoid all nicotine.
Pulmonary function tests to assess lung health.
* Blood work and X ray
frequent follow-up visits so the lung transplant team can make sure the pt is healing properly
monitor for S/S of reactions:
  * hyperacute rejection (minutes to hours post transplant)
    * Acute desaturation
    * Tissue hypoxia
    * pleural effusion
  * acute rejection (first 12 weeks post transplant)
    * Fatigue
    * Dyspnea
    * Fever
    * Pleural effusions
    * Obstructive bronchiolitis
  * chronic rejection (5 years post transplant) aka obliterative bronchitis (OB) (inflammation and fibrosis of small airways)
    * progressive SOB
    * decreased exercise intolerance
    * airflow limitation
    * progressive decline in pulmonary function

Possible reasons why people might reject the idea of OTx (Sole)

It is common for families with loved ones who are pronounced brain dead to be apprehensive about signing up for organ donation because their loved one may not look as if they have passed. They might appear to be alive because the ventilator is pushing air in and out of their lungs which causes their chest to artificially rise and fall. Their loved one will also have a pulse and warm skin because artificial support is being provided to the heart and blood pressure by vasoactive drugs and IV fluids
It is also important to keep in mind that any discussion of death touches on cultural, personal, and religious perspectives and, as such, should be addressed carefully and with sensitivity
  * African Americans might not want to donate, including a distrust of doctors. "People sometimes believe that not only will they not try to save your life, but will try to use your organs as experiments,"
  * Mistrust of the medical community among African Americans is not uncommon, and not without historical justification
    * Not on the test but important insight:
      * In the Tuskegee syphilis experiment, black men in Alabama were promised free medical care, and then unknowingly signed up for a long-term research study into the effects of syphilis. When a cure became available, the men were denied treatment so that the study could continue
      * Henrietta Lacks went to John Hopkins for cervical cancer treatment, where a doctor took samples from her cervix and used them to develop one of the most-used cell research lines – all without her permission or knowledge
      * So important to keep this history in mind

How to identify potential donor

OPO coordinator completes a thorough physical examination and obtains an extensive medical and social history from the patient’s medical records and family
Medical history includes the presence or absence of DM, HTN, malignancy, and mechanism of death
History of active malignancy disqualifies a patient from organ donation
Donation from a pt with a long cancer free interval is an option depending on tumor type and selective donor use (case by case basis)
A social history of cigarette use, heavy alcohol use, IV drug use, and any other risk factor for bloodborne illnesses establishes a donor risk profile
Lab tests:
  * BMP
  * Hepatic panel
  * Lipid profile
  * CBC
  * Thyroid panel
  * Urinalysis
  * ABO typing and human leukocyte antigen histocompatibility (helpful in predicting organ rejection)
Serologic testing screens the potential donor for transmissible diseases such as:
  * HIV
  * Hep A,B, C
  * EBV
  * Sexually transmitted diseases
    * increased risk donor: someone who has documented risk of exposure to HIV
    * standard criteria donor: pt who is younger than 60 years old who has no significant comorbidities affecting organ function
    * extended criteria donor: over 60, pos for hep C, donor liver recovered and not transplanted in the last 12 hours, accumulation of fat within liver, etc. (families ultimately decide on acceptance of organs from these donors
The OPO coordinator identifies potential recipients for organs that can be donated
UNOS matches organs to potential recipients
The OPO coordinator then contacts the transplant surgeon on call to complete the organ offer

Process for hematopoietic stem cell transplantation (HSCT) (chapter 37)

standard treatment for the patient with acute leukemia who has a closely matched donor and who is in temporary remission after induction therapy (induction therapy includes wiping bone marrow clean of cancerous cells prior to transplant)
It can also be used for some forms of chronic leukemia, MDS, lymphoma, multiple myeloma, aplastic anemia, sickle cell disease, and many solid tumors
Stem cells for transplantation can be obtained directly from the donor’s bone marrow or, more often, from his or her peripheral blood
The new cells go to the marrow and then begin the process of hematopoiesis, which results in normal, properly functioning blood cells and ideally a permanent cure
Transplant is classified by source of donor cells
  * Autologous: self donation ex: bone marrow harvest, peripheral stem cell apheresis, umbilical cord blood
  * Syngenic: pts HLA identical twin or other identical sibling ex: bone marrow harvest or peripheral stem cell apheresis
  * Allogenic: HLA-matched relative (donation via bone marrow harvest), unrelated HLA-matched donor (donation via peripheral stem cell apheresis), and mismatched or partially matched donor ex: donor registries (donation via umbilical cord blood)
Transplantation has five phases: stem cell obtainment, conditioning regimen, transplantation, engraftment, and posttransplantation recovery
  * Obtaining the stem cells:
    * Stem cells are taken from the patient directly (autologous stem cells)
      * an HLA-identical twin (syngeneic stem cells)
      * an HLA-matched person (allogeneic stem cells)
      * For allogeneic HSCT, best results occur when the donor is an HLA-identical sibling; however, transplant also can be successful between closely but not perfectly matched HLA types
      * blood type compatibility is no included in donor criteria
        * Bone marrow harvesting:

occurs after a matching donor has been identified by tissue typing

The procedure occurs in the operating room, where marrow is removed through multiple aspirations from the iliac crests

About 500 to 1000 mL of marrow is aspirated, and the donor’s marrow regrows within a few weeks

The marrow is then filtered and, if autologous, is treated to rid the marrow of any remaining cancer cells and then usually frozen (allogeneic marrow is transfused into the recipient immediately)

Peripheral blood stem cell harvesting:

stem cells that have been released from the bone marrow and circulate within the blood

stem cells are collected by apheresis (withdrawing whole blood, filtering out the cells, and returning the plasma to the patient)

One to five apheresis procedures, each lasting 2 to 4 hours, are needed to obtain enough stem cells for transplantation

Cord blood harvesting:

obtains stem cells from umbilical cord blood of newborns, which has a high concentration of stem cells

These cells are obtained through a simple blood draw from the placenta after birth and before the placenta detaches

The blood is sent to the Cord Blood Registry for processing and storage. Stem cells may be used later for an unrelated recipient or stored in case the infant develops a serious illness later in life and needs them

Conditioning regimen:
  * outlines the timing and steps involved in transplantation
  * The day the patient receives the stem cells is day T−0 (Before transplantation, the conditioning days are counted in reverse order from T−0)
  * The patient first undergoes a conditioning regimen, which varies with the diagnosis and type of transplant to be received
  * The conditioning regimen serves two purposes: (1) to “wipe out” the patient’s own bone marrow, thus preparing him or her for replacement by a new immune system; and (2) to give high doses of chemotherapy and/or radiotherapy to rid the patient of cancer cells (myeloablation)
  * Transplantation:
    * Frozen marrow, PBSCs, or umbilical cord blood cells are thawed and infused through the patient’s central catheter as in an ordinary blood transfusion
    * Do not use blood administration tubing to infuse stem cells because the cells may be trapped in the filter, resulting in the patient receiving fewer stem cells. Usually standard, larger-bore, IV administration tubing is used
  * Engraftment:
    * The transfused PBSCs and marrow cells circulate briefly in the peripheral blood. The stem cells then “home in” on the marrow-forming sites of the patient’s bones and establish residency there
    * the successful “take” and growth of the transplanted cells in the patient’s bone marrow, is key to the whole transplantation process
    * The average time to engraftment ranges from 14 to 21 days. Growth factors may be given to aid engraftment
    * When engraftment occurs, the patient’s WBC, RBC, and platelet counts begin to rise
    * Engraftment syndrome (ES) with fever and weight gain may occur at this time
      * Monitoring engraftment involves checking the patient’s blood for chimerism. Which is the presence of blood cells that show a genetic profile or marker different from those of the patient